<!--
  ========================LICENSE_START=================================
  screenit-web
  %%
  Copyright (C) 2012 - 2020 Facilitaire Samenwerking Bevolkingsonderzoek
  %%
  This program is free software: you can redistribute it and/or modify
  it under the terms of the GNU Affero General Public License as published by
  the Free Software Foundation, either version 3 of the License, or
  (at your option) any later version.
  
  This program is distributed in the hope that it will be useful,
  but WITHOUT ANY WARRANTY; without even the implied warranty of
  MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE.  See the
  GNU General Public License for more details.
  
  You should have received a copy of the GNU Affero General Public License
  along with this program.  If not, see <http://www.gnu.org/licenses/>.
  =========================LICENSE_END==================================
  -->
<html xmlns:wicket="http://wicket.apache.org">
<wicket:panel>
    <div class="modal-header">
        <button data-dismiss="modal" class="close" type="button">x</button>
        <h3>Huisartsgegevens invullen</h3>
    </div>
    <div class="modal-body">
        <div style="display: block;" id="handmatig"
             class="form-container huisarts-handmatig form-horizontal">
            <h2>Huisarts gegevens</h2>
            <form wicket:id="form">
                <div class="control-group">
                    <label class="control-label">Huisartsnaam</label>
                    <div class="controls">
                        <input type="text" value="" class="input-large"
                               wicket:id="huisartsNaam"/>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Praktijknaam</label>
                    <div class="controls">
                        <input type="text" value="" class="input-large"
                               wicket:id="praktijkNaam"/>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Adres</label>
                    <div class="controls">
                        <input type="text" value="" class="input-large"
                               wicket:id="praktijkAdres"/>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Postcode / plaats</label>
                    <div class="controls">
                        <input type="text" value="" class="postcode required" wicket:id="praktijkPostcode"/> <span class="divider">/</span>
                        <div class="append-woonplaats">
                            <input type="text" value="" class="plaatsnaam required" wicket:id="praktijkPlaats"/>
                        </div>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Telefoonnummer</label>
                    <div class="controls">
                        <input type="text" value="" class="input-large"
                               wicket:id="telefoonnummer"/>
                    </div>
                </div>
                <div class="control-group">
                    <label class="control-label">Faxnummer</label>
                    <div class="controls">
                        <input type="text" value="" class="input-large"
                               wicket:id="faxnummer"/>
                    </div>
                </div>
            </form>
        </div>
    </div>

    <div class="modal-footer">
        <button data-dismiss="modal" class="btn" wicket:id="annuleren">Annuleren</button>
        <button id="huisartsOpslaanBtn" data-dismiss="modal"
                class="btn btn-primary" wicket:id="opslaan">Selecteer
        </button>
    </div>
</wicket:panel>
</html>
